White, Helen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section } '� Burial - Transit Permit
Name First Middle Last Sex
13 Helen A.White Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/15/2017 66 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
- Manner of Death X❑ Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Jean Vanauken PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 654
❑Burial Date Cemetery or Crematory �.
12/20/2017 Pine View Crematory
❑Entombment Address
.®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
• and/or Address
Hold
/f7
Date Point of
❑Transportation Shipment
- by Common Destination
Carrier
❑Disinterment
Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/20/2017 Registrar of Vital Statistics W.p6ertACurtis 'Ffectronically Signed
(signature)
District Number 5601 Place Glens Falls, New York
- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /2 J2)J i, Place of Disposition RI,(. iZ� L_i 6-"-4) y
l (address)
(section) (lot number) (grave number)
- Name of Sexton o Ferso -n Charge of Premises J �c-n G r►ta c:�1
= (please print)
Signature Title C re- in 0-1/
(over)
DOH-1555 (02/2004)